SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO Civil Mediation Program Mediator Application Please submit completed application to: Milica Novakovic, Mediation Program Coordinator Superior Court of California, County of San Diego 220 West Broadway, Room 2106 San Diego, CA 92101 E-mail: milica.novakovic@sdcourt.ca.gov Fax: (619) 450-5690 1. Contact Information a. Name: b. Organization(s) / Firm name(s): c. Mailing address: City: d. Zip: E-mail: e. State: Telephones: Daytime: Evening: Fax: Cell: 2. Education and Training a. Education: Section II.B.1.a. of the Mediator Manual requires a bachelor’s degree from an accredited college or university. Please describe your education and include legal education, if applicable (please include the name(s) and location(s) of the institution(s) attended, the dates of attendance, and the specific degree(s) conferred): b. Training: Section II.B.1.b. of the Mediator Manual requires that you complete at least thirty-two (32) hours of mediator training from a recognized training provider, or other equivalent training. Please describe your mediator training (please specify the name(s) and location(s) of the training provider(s), the dates of the training(s), the number of hours of classroom training, experiential training, and advanced or specialized training as more fully described in Section II.B.1.b. of the Mediator Manual. Attach additional pages, if necessary.): SDSC CIV-023 (New 9/08) MEDIATOR APPLICATION Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com 3. Mediation Experience a. Minimum Experience Requirement: Section II.B.2. of the Mediator Manual requires you to “have mediated or comediated at least six mediations of at least two hours in length. Co-mediations with a mediator who is already on the court’s panel would serve to satisfy this minimum requirement. ‘Mediations’ refers to the number of cases mediated, not the number of mediation sessions. Settlement conferences or arbitrations conducted as mediations or that become mediations do not serve to satisfy this requirement.” List at least six mediations below, which serve to satisfy this requirement (for each mediation, please specify the date(s), panel or organization if applicable, case name, court, case type, total number of hours in mediation, whether you were the sole mediator or co-mediator, the name and contact information of the co-mediator if applicable, and result): b. Total number of cases mediated: . How many cases did you mediate since completing the minimum mediation training requirements listed in 2.b., above: _______? The principal portion of my mediation practice is in the following case type(s) (if more than one case type is listed, please provide percentage estimates totaling 100%; i.e., 50% breach of contract and 50% landlord/tenant): c. d. Additional Mediation Experience: Please describe below any additional mediation experience. SDSC CIV-023 (New 9/08) MEDIATOR APPLICATION Page 2 of 5 4. Experience as a Neutral a. Do you now serve or have you previously served as a mediator, arbitrator, or other type of neutral on an ADR panel or in an ADR program, including but not limited to court panels and court programs? Yes No (If yes, describe your prior service below. Please include the names and locations of the court(s) or ADR organization(s), the type(s) of panel(s), the approximate number and types of cases handled, the dates of service, and if you are no longer serving on a particular panel or in a particular program, your reason(s) for suspending or terminating your service.) b. Have you ever been suspended or removed as an ADR neutral, either temporarily or permanently, by a court or ADR organization? Yes No (If yes, describe the circumstances below, including the court, the date you were suspended or removed, and the reason(s) for your suspension or removal. Attach additional pages if necessary.) 5. Other Professional and Personal Qualifications a. b. California State Bar number, if applicable: I am also admitted to practice law in the states listed below: State: Date admitted: Bar No: Date of admission: Years of active membership: State: Date admitted: Bar No: Years of active membership: Are you in good standing in each state where you are licensed to practice law? Yes No (If not, provide an explanation in an attachment.) d. I am certified as a specialist by the State Bar of California Board of Legal Specialization or by an organization whose certification program has been accredited by the State Bar of California. Areas of specialization: c. e. I am certified by other states or ADR organizations with a certification program as a mediator or other type of neutral. For each certification, provide the name, location and contact information of the organization(s), the date(s) of certification, and the minimum requirements for the certification. f. Have you ever been disciplined by the State Bar of California, a bar association, a public disciplinary or professional licensing agency or an ADR organization or entity in any state or by a court of record, including but not limited to being sanctioned (other than being sanctioned for violation of the Civil Discovery Act) or held in contempt? Yes No g. Do you have, or have you had, any disciplinary action pending against you by the State Bar of California, a bar association, a public disciplinary or professional licensing agency or an ADR organization or entity in any state or by a court of record, including but not limited to any proceeding for the imposition of sanctions (other than sanctions for violation of the Civil Discovery Act) or for contempt? Yes No h. Have you ever been convicted or pleaded no contest to a felony or misdemeanor? Yes No i. Has there been any entry of judgment against you in any civil action for actual fraud or punitive damages? Yes No j. Have you ever been a party to any legal proceeding? Yes No k. Have you ever been declared a vexatious litigant? Yes No (If you answered yes to questions 5 f, g, h, i, j, or k, provide additional information in an attachment.) SDSC CIV-023 (New 9/08) MEDIATOR APPLICATION Page 3 of 5 6. Facilities List all facilities in which you provide mediation services (for each facility listed, please briefly describe the facility and specify its location and whether or not it can accommodate persons with disabilities): 7. Additional Information Please respond to the following, if applicable (attach additional pages if necessary): a. The following facts concerning my background, situation, or circumstances may positively or negatively reflect on me or on my suitability for appointment and should be disclosed to the court. b. I ask the court to consider the following additional facts in support of my appointment: 8. References Please list at least three professional references, two of which must be from a party or attorney who appeared before you in mediation. For each reference, provide their name, address, telephone number, and e-mail address, and also provide the date(s), case name(s) and case type(s), and the reference’s role in the mediation (attorney, party or comediator), if applicable. SDSC CIV-023 (New 9/08) MEDIATOR APPLICATION Page 4 of 5 9. I understand and acknowledge that the approval of my application to serve as a mediator on the court’s Civil Mediation Program panel is solely at the discretion of the court. 10. I have read the Mediator Manual and, if approved to serve, will comply with all provisions contained in the Mediator Manual as well as all applicable California Rules of Court, local rules, and court policies and procedures concerning mediators on the court’s Civil Mediation Program panel. I declare under penalty of perjury under the laws of the State of California that the foregoing, including statements made in all attachments, is true and correct. I understand that any misstatement or omission of material fact may disqualify me from serving as a mediator on the court’s Civil Mediation Program panel. Date: Type or print name of applicant Signature of applicant (This application is not complete unless the Release of Liability below is signed by the applicant.) RELEASE OF LIABILITY I HEREBY RELEASE THE SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO AND ITS OFFICERS, EMPLOYEES, AGENTS, AND ASSIGNS FROM ANY LIABILITY OR DAMAGE WHICH MAY RESULT FROM FURNISHING ANY OF THE INFORMATION REQUESTED IN THIS MEDIATOR APPLICATION. Date: Type or print name of applicant Signature of applicant FOR INTERNAL USE ONLY: Approved SDSC CIV-023 (New 9/08) Disapproved on ____________________________ (date) MEDIATOR APPLICATION Page 5 of 5